Intermediate Medical Coding

Intermediate Medical Coding
Orthopedist Dr. Hansen is visiting Andrew, a 72-year-old longtime patient, since he has been experiencing acute knee pain in both knees and has fallen multiple times in the past two months. Dr. Hansen performs a comprehensive history and physical exam requiring somewhat sophisticated medical decision making, including X-rays of both knees revealing advanced osteoarthritis. Dr. Hansen gives the patient a tripod cane that can be adjusted for height and safety instructions because the patient has been falling frequently.

Intermediate Medical Coding

Dr. Hansen prescribes the patient over-the-counter glucosamine and chondroitin sulfate and pain relievers as needed, with a follow-up visit set for one month later.

E&M code:______________________________

ICD-10-CM code: ________________________

ICD-10-CM code: ________________________

CPT code: ______________________________

HCPCS code: ___________________________

Andrew had an arthroscopy planned for this week after he came back for his follow-up appointment last week complaining of worsening pain and swelling in his right knee. Today he has come in for a diagnostic arthroscopy of his right knee, which will include a synovial biopsy. This 72-year-old male patient is being given anesthesia by a CRNA under the watchful eye of a physician.

Intermediate Medical Coding
Andrew also suffers from well-controlled essential hypertension and osteoarthritis. Immediately following surgery, the patient was fitted with a ready made canvas longitudinal knee immobilizer.


Anesthesia: _____________________________

Concurrent Care Modifier: __________________

Physical Status Modifier: ___________________


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